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Using the plan > Precertification Process
Please remember that, to take full advantage of your benefits as a member of Hometown Health Providers, you must understand which services require precertification. You are responsible for ensuring that you notify Hometown Health before certain services and procedures are performed.
The following services require precertification from Hometown Health:
- All inpatient hospitalizations
- All inpatient rehabilitation
- All same day surgery (diagnostic and screening colonoscopies do not require authorization).
- All SNF admissions
- DME over $100
- Home Health Services
- Transplant Services (excluding outpatient diagnostic testing, laboratory or x-ray)
- Pain-management services, including trigger-point injections
- Office visits to specialists (excluding chiropractic and in office procedures). Please note: PPO does not require authorization for visits to specialists.
- Some medications also require authorization. Please refer to the formulary for information on specific medications.
Hometown
Health performs Utilization Review only to precertify the medical necessity of the above services for the care and treatment of an illness or injury. Hometown Health will also review for alternative methods of medical care or treatment. Precertification by Hometown Health does not guarantee that all charges are covered under the policy. Charges submitted for payment are subject to all of the terms of the policy.
If a member fails to secure a precertification prior to receiving the services listed above, benefits are reduced to a 50 percent coinsurance level. This penalty is in addition to any other deductible and copayment under the policy.
It is important to establish a relationship with your physician and to remind him or her of the importance of the precertification requirements. Either you or your physician can call our Customer Services Department.
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